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OCC2019：何奔教授丨冠状动脉非阻塞性心肌梗死(MINOCA)

2019-05-30 Fiona MedSci原创

OCC2019何奔教授
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OCC 2019今天正式召开，在上海医学会心血管病年会上，诸位大咖为大家详细解读了心血管各类指南。何奔教授从自己亲身经历的两个病案，为大家介绍了什么是MINOCA。什么是MINOCA？ 2017：ESC STEMI指南       没有冠状动脉受累的心肌疾病（如心肌炎和Takotoubo综合征），临床表现与心肌梗死类似，是一种心肌损伤状态 

OCC 2019今天正式召开，在上海医学会心血管病年会上，诸位大咖为大家详细解读了心血管各类指南。

何奔教授从自己亲身经历的两个病案，为大家介绍了什么是MINOCA。


什么是MINOCA？

 2017：ESC STEMI指南
       没有冠状动脉受累的心肌疾病（如心肌炎和Takotoubo综合征），临床表现与心肌梗死类似，是一种心肌损伤状态
 2018：Beltrame JF，澳大利亚
        MONICA仅用于指代缺血相关的心肌坏死
 2018：ESC，ACC，AHA，WHF
        MINOCA的诊断表明心肌细胞的损伤由缺血导致（即排除了非缺血性因素，如心肌炎）

MINOCA的诊断标准
急性心肌梗死的诊断标准（第三版通用定义）
   心肌损伤标志物-升高或下降（＞99th百分位）
   临床依据—至少满足以下一条
      心肌缺血症状
      心电图可见新发的ST-T改变或LBBB
      病理性Q波形成
      影像学证据提示新出现的存活心肌减少或室壁运动异常
      冠脉造影或尸检发现冠脉内血栓
   非梗阻性冠脉病变
      冠脉造影：正常（＜30%＝或轻度CAD（30%≤CAD＜50%＝
   未能发现引起临床表现的特定疾病
      需进一步探究潜在病因

MONICA的病因
斑块破裂


冠脉痉挛

  冠状动脉痉挛激发试验表明27%MINOCA患者存在可诱导性痉挛。
  微血管痉挛也是MINOCA的潜在病因。冠状动脉痉挛激发试验虽没有诱导出大血管痉挛，但可以检测到超敏肌钙蛋白升高。
  可考虑诊断：反复发生的静息心绞痛+服用短效硝酸酯类药物后症状缓解+出现暂时性缺血的ST段改变

冠脉血栓栓塞

  血栓形成倾向筛查研究显示14%MINOCA患者存在遗传倾向，遗传性血栓形成倾向性疾病包括v因子Leiden变异及蛋白s和c缺乏冠状动脉栓塞的可能病因包括：心房颤动、瓣膜性心脏病、心脏肿瘤和医源性空气栓塞等

冠脉夹层

  自发性冠脉夹层往往通过造成管腔阻塞导致急性心肌梗死，但冠脉造影有时未能显示管腔阻塞
  没有内膜撕裂的冠状动脉壁内血肿也有类似表现
  女性更常见
  多数病例存在血管床纤维性发育不良
  由于激素、怀孕及分娩等因素的影响，血管内膜-中膜的组成发生变化
  提倡药物保守治疗，不推荐他汀类药物

2型心肌梗死

  心肌氧供需失衡导致的心肌细胞坏死，而无冠脉斑块破裂及冠脉阻塞等病变
  2型AMI的病因包括：贫血、快慢综合征、呼吸衰竭、低血压、休克、伴或不伴左室肥厚的重度高血压等
  ECG显示2型AMI占NSTEMI患者的97%
  治疗：尽可能纠正导致供养和需氧失衡的潜在疾病
  阿司匹林和β受体阻滞剂可能有益



MINOCA的推荐诊断流程



总结


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    2019-07-01 tomyang96

    #阻塞#

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=1696885, encodeId=e24c1696885c9, content=<a href='/topic/show?id=d2e99e651e4' target=_blank style='color:#2F92EE;'>#阻塞#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=97651, encryptionId=d2e99e651e4, topicName=阻塞)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a23129903429, createdName=tomyang96, createdTime=Mon Jul 01 21:03:00 CST 2019, time=2019-07-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1927933, encodeId=493b192e93357, content=<a href='/topic/show?id=f7fb13216dc' target=_blank style='color:#2F92EE;'>#OCA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13216, encryptionId=f7fb13216dc, topicName=OCA)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c39f145, createdName=smlt2008, createdTime=Thu Sep 19 02:03:00 CST 2019, time=2019-09-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1975602, encodeId=322d19e560230, content=<a href='/topic/show?id=e89111e9239' target=_blank style='color:#2F92EE;'>#MINOCA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=11792, encryptionId=e89111e9239, topicName=MINOCA)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1dbc2500219, createdName=huagfeg, createdTime=Wed Apr 08 14:03:00 CST 2020, time=2020-04-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1353088, encodeId=e38f13530880b, content=<a href='/topic/show?id=1d931321816' target=_blank style='color:#2F92EE;'>#OCC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13218, encryptionId=1d931321816, topicName=OCC)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Sat Jun 01 09:03:00 CST 2019, time=2019-06-01, status=1, ipAttribution=)]
    2019-09-19 smlt2008

    #OCA#

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=1696885, encodeId=e24c1696885c9, content=<a href='/topic/show?id=d2e99e651e4' target=_blank style='color:#2F92EE;'>#阻塞#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=97651, encryptionId=d2e99e651e4, topicName=阻塞)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a23129903429, createdName=tomyang96, createdTime=Mon Jul 01 21:03:00 CST 2019, time=2019-07-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1927933, encodeId=493b192e93357, content=<a href='/topic/show?id=f7fb13216dc' target=_blank style='color:#2F92EE;'>#OCA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13216, encryptionId=f7fb13216dc, topicName=OCA)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c39f145, createdName=smlt2008, createdTime=Thu Sep 19 02:03:00 CST 2019, time=2019-09-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1975602, encodeId=322d19e560230, content=<a href='/topic/show?id=e89111e9239' target=_blank style='color:#2F92EE;'>#MINOCA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=11792, encryptionId=e89111e9239, topicName=MINOCA)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1dbc2500219, createdName=huagfeg, createdTime=Wed Apr 08 14:03:00 CST 2020, time=2020-04-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1353088, encodeId=e38f13530880b, content=<a href='/topic/show?id=1d931321816' target=_blank style='color:#2F92EE;'>#OCC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13218, encryptionId=1d931321816, topicName=OCC)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Sat Jun 01 09:03:00 CST 2019, time=2019-06-01, status=1, ipAttribution=)]
    2020-04-08 huagfeg

    #MINOCA#

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=1696885, encodeId=e24c1696885c9, content=<a href='/topic/show?id=d2e99e651e4' target=_blank style='color:#2F92EE;'>#阻塞#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=97651, encryptionId=d2e99e651e4, topicName=阻塞)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a23129903429, createdName=tomyang96, createdTime=Mon Jul 01 21:03:00 CST 2019, time=2019-07-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1927933, encodeId=493b192e93357, content=<a href='/topic/show?id=f7fb13216dc' target=_blank style='color:#2F92EE;'>#OCA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13216, encryptionId=f7fb13216dc, topicName=OCA)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c39f145, createdName=smlt2008, createdTime=Thu Sep 19 02:03:00 CST 2019, time=2019-09-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1975602, encodeId=322d19e560230, content=<a href='/topic/show?id=e89111e9239' target=_blank style='color:#2F92EE;'>#MINOCA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=11792, encryptionId=e89111e9239, topicName=MINOCA)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1dbc2500219, createdName=huagfeg, createdTime=Wed Apr 08 14:03:00 CST 2020, time=2020-04-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1353088, encodeId=e38f13530880b, content=<a href='/topic/show?id=1d931321816' target=_blank style='color:#2F92EE;'>#OCC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13218, encryptionId=1d931321816, topicName=OCC)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Sat Jun 01 09:03:00 CST 2019, time=2019-06-01, status=1, ipAttribution=)]
    2019-06-01 zhaojie88

    #OCC#

    0